Method and apparatus for providing suture in a passageway

ABSTRACT

A surgical apparatus may include a guide apparatus to be used in an arthroscopic procedure and to interact with a passageway through a body portion formed by intersecting first and second holes that may lead into the body portion from different positions, e.g., from two different locations on a bone. The guide apparatus may include first and second guide members having first and second passages, respectively, that communicate with the first and second holes. The surgical apparatus may also include a suture retriever arranged to retrieve, from the second passage, a suture fed into the first passage. A method may include forming a passageway including first and second intersecting holes. First and second guide tubes may be positioned relative to the first and second holes, a suture or suture-like material may be provided into the first guide tube, and the suture or suture-like material may be retrieved from the second guide tube.

BACKGROUND OF INVENTION

1. Field of Invention

This invention relates to methods and apparatus for providing suture ina passageway.

2. Discussion of Related Art

Providing a passageway in a body portion, such as a bone, is a commonprocedure in surgical repair. For example, tendon damage frequentlyrequires surgery for repair, e.g., to reattach a torn or separatedtendon to the bone to which the tendon would normally be attached. Insome cases, reattachment of the tendon or other material is performedusing a passageway through bone, i.e., a transosseous tunnel. Forexample, rotator cuff injuries typically involve damage to the rotatorcuff tendon such that the tendon, or at least a portion thereof,requires reattachment to the humerus. FIG. 1 shows a schematic diagramof a humerus 1 and a portion of a rotator cuff tendon 2 that is normallyattached to the head of the humerus. In one type of damage to therotator cuff, the tendon 2 may detach or be partially torn from thehumerus 1, such as that shown schematically in FIG. 2. Such damage maybe repaired by reattaching the rotator cuff tendon to the humerus 1 by asuture or other fixation so that the body's normal healing processes cannaturally effect reattachment of the tendon to the bone. One repairtechnique for reattaching the rotator cuff 2 to the humerus 1 involvesforming a hole in the bone and fixing an anchor 101 at a margin betweenthe articulating portion 11 of the humerus 1 and the humerus' greatertuberosity 12. A suture 102 is secured to the rotator cuff 2 and theanchor 101, and the suture 102 is tensioned so that the rotator cuff 2is held in place close to the humerus 1. Thereafter, the body mayreestablish the proper attachment of the rotator cuff 2 to the humerus1.

In another repair technique, a passageway may be formed through thehumeral head, e.g., extending from a point at the margin to a locationon the lateral side of the humerus. U.S. Pat. No. 5,330,468 discloses adrill guide for forming such a passageway in the humeral head andsubsequently feeding suture through the passageway. One end of a sutureplaced in the rotator cuff may be passed through the passageway, andanother end of the suture may be extended around the greater tuberosity(or passed through another adjacent passageway in the bone), and the twoends joined together to secure the tendon in place.

SUMMARY OF INVENTION

Aspects of the invention provide a guide apparatus for use with apassageway in a body portion, such as a portion of bone, where thepassageway is formed by two intersecting holes. The guide apparatus maybe arranged so that two guide members can be associated with thepassageway in such a way (e.g., partially positioned in the passageway)that passages in the guide members are positioned adjacent each other inthe passageway, e.g., to facilitate passing a suture from one guidemember to the other. The guide apparatus may alternately, oradditionally, be used to form all or part of the passageway in the bodyportion. For example, guide members in the apparatus may be used toperforate the body portion, guide the movement of a perforator, and/ordefine the starting point of an opening when forming one or two holesthat form the passageway. The guide apparatus may be used in anarthroscopic or open surgical procedure.

In one aspect of the invention, a surgical apparatus may include a guideapparatus constructed and arranged to be used in an arthroscopicprocedure and to interact with a passageway through a body portionformed by intersecting first and second holes. The first and secondholes may lead into the body portion from different positions, e.g.,from two different locations on a bone. The guide apparatus may includefirst and second guide members having first and second passages,respectively, that communicate with the first and second holes,respectively. The surgical apparatus may also include a suture retrieverarranged to retrieve, from the second passage, a suture fed into thefirst passage.

In another aspect of the invention, a method for surgical repairincludes forming a passageway through a body portion, where thepassageway is formed by first and second intersecting holes in the bodyportion. First and second guide tubes may be respectively positionedrelative to the first and second holes. A suture or suture-like materialmay be provided into the first guide tube, and the suture or suture-likematerial may be retrieved from the second guide tube.

In one aspect of the invention, an apparatus for providing a passagewayin a surgical procedure includes a reference structure, and first andsecond guide members each having distal and proximal ends and a passageleading to the distal end. The first guide member may be adapted to bearranged in a first position relative to the reference structure, andthe second guide member may be adapted to be arranged in a secondposition relative to the reference structure. When in the first andsecond positions, the first and second guide members may be arranged sothat the first and second passages are adjacent, e.g., the distal endsof the first and second guide members may be adjacent each other. Thisarrangement may allow for the first and second guide members to be usedin forming a passageway in a body part, such as a portion of bone,and/or may provide a passageway for passing a suture or suture-likematerial from the first guide member to the second guide member. Forexample, one of the guide members may be used to guide the movement of aperforator, such as a drill, punch or awl, so as to form the passagewayin a desired location. Alternately, or in addition, the guide apparatusmay be used with a pre-formed passageway to pass a suture or suture-likematerial through the passageway.

In one aspect of the invention, a method for performing a surgicalrepair includes providing a first hole in a body portion, positioning aguide relative to the first hole, and forming a second hole using theguide to define a location of the second hole so that the second holeintersects with the first hole and forms a passageway through the bodyportion. The guide may be used to provide a suture or suture-likematerial through the passageway, and a repair suture may be secured to amaterial to be secured relative to the body portion. At least a portionof the repair suture may be positioned in the passageway, and thematerial secured relative to the body portion using the repair suture.

In another aspect of the invention, a method for forming a passageway inbone includes providing a first hole into bone of a humerus, andsecuring a first guide member relative to the first hole. The firstguide member may be positioned with respect to a reference structure,and a second hole may be formed in the bone using the referencestructure to define the location of the second hole relative to thefirst hole. The second hole may be formed so as to intersect the firsthole and form a passageway through the bone. At least a portion of asuture may be passed through the passageway, and a rotator cuff tendonmay be secured relative to the bone using the suture.

BRIEF DESCRIPTION OF DRAWINGS

Various aspects of the invention are described with reference toillustrative embodiments, wherein like numerals reference like elements,and wherein:

FIG. 1 is a schematic diagram of a head of a humerus and attachedrotator cuff tendon;

FIG. 2 shows a prior art technique for repairing a rotator cuff injury;

FIG. 3 is a schematic diagram of a tissue repair arrangement inaccordance with an aspect of the invention;

FIGS. 4-6 show the use of a needle for placing a suture in a tissue inaccordance with the invention;

FIG. 7 shows a needle in engagement with a cannula in accordance with anaspect of the invention;

FIG. 8 shows an illustrative arrangement for engaging a needle with acannula in one embodiment;

FIG. 9 shows an illustrative arrangement for engaging a sleeve andneedle assembly with a cannula in accordance with another embodiment;

FIG. 10 shows a guide apparatus used in forming a passageway inaccordance with the invention;

FIG. 11 shows the use of a guide apparatus for passing a suture or otherelement through a transosseous passageway in accordance with theinvention;

FIG. 12 shows a technique for passing a suture placed in a tissuethrough a passageway;

FIG. 13 shows the engagement of a suture with a suture fixation devicein accordance with the invention;

FIG. 14 shows the placement of a suture fixation device relative to thebone in accordance with the invention;

FIG. 15 shows a suture fixation device engagement tool in engagementwith a suture fixation device in accordance with the invention; and

FIGS. 16A-B and 17A-B show side and rear views, respectively, ofillustrative embodiments of suture fixation devices in accordance withthe invention.

DETAILED DESCRIPTION

This invention is not limited in its application to the details ofconstruction and the arrangement of components set forth in thefollowing description or illustrated in the drawings. The invention iscapable of other embodiments and of being practiced or of being carriedout in various ways. Also, the phraseology and terminology used hereinis for the purpose of description and should not be regarded aslimiting. Also, the term “guide” or “guiding” as used herein meansactually guiding an element in its movement, and/or providing somereference for the location of an element. For example, “guiding” theformation of a hole in a body portion may mean guiding a bone perforatorwhen actually forming the hole and/or providing a starting location forthe hole formation.

Various aspects of the invention are described below with reference tospecific embodiments. For example, aspects of the invention aredescribed in the context of performing a rotator cuff repair. However,it should be understood that aspects of the invention are notnecessarily restricted to rotator cuff repair techniques, or even tosurgical techniques performed on a shoulder. Rather, various aspects ofthe invention may be used in any suitable surgical procedure. Inaddition, various aspects of the invention may be used alone, and/or incombination with any other aspects of the invention.

In another aspect of the invention, a passageway formed through a bodyportion, such as bone, may be made by first and second intersectingholes. That is, the first and second holes may be formed into the bodyportion so each originate at different starting points and intersectwithin the body portion. The holes may be formed at an angle to eachother or may be colinear. A guide may be used to define the location ofthe first and/or second hole, e.g., may be used to guide the movement ofa bone perforator when forming the first and/or second holes, and/or maybe used to locate a starting point for the formation of the first orsecond holes. In addition, or alternately, the guide may be used to passa suture through the passageway. For example, a portion of the guide maybe secured relative to one or both of the holes and a suture or othermaterial may be passed through the guide portion when passing the sutureor other material through the passageway.

In one aspect of the invention, a guide apparatus may be used to formone or two holes used to form a passageway in a body portion and/or topass a suture or other material through the passageway. For example, afirst guide member may be secured relative to a first hole formed inbone. A second guide member may be arranged so that its orientationrelative to the first guide member is known. The second guide member maybe used to guide the identification of a starting point for theformation of the second hole and/or guide the movement of a perforatoror other device to form a second hole so that the orientation of thesecond hole is arranged in a known way relative to the first hole.

Alternately, the second guide member may be secured relative to a secondhole that intersects with the first hole. The first and second guidemembers may be positioned relative to each other, e.g., using areference structure, so that distal ends of the guide members arepositioned adjacent each other in the passageway. Suture or othermaterial may be introduced into one of the guide members and fed to apoint adjacent the other guide member. The suture or other material maybe retrieved from the guide member, for example, by a hook-shapedmember, grasper or other suture retriever.

Various aspects of the invention may be used in an open surgicalprocedure or in a closed procedure, such as an arthroscopic procedure.For example, a guide apparatus may be used in an open or closedprocedure as an aid in forming a passageway through a body portion, forpassing a suture or other material through a passageway, or for bothforming a passageway and passing a suture or other material through thepassageway. In a closed procedure, each guide member in the apparatusmay be passed through respective portals. Portions of the guideapparatus may remain outside of the body, however, such as the referencestructure. Also, various aspects of the invention may be used in anysuitable surgical or other procedure involving any suitable bodyportions, such as bone, muscle, skin, vascular structures, digestivestructures, or other tissue, implants, mesh, or other medical devices,etc.

These and other aspects of the invention will be apparent from thefollowing description.

FIG. 3 shows a schematic diagram of a surgical repair in accordance withaspects of the invention. As discussed above, although aspects of theinvention are described with reference to a rotator cuff repair for easeof reference and understanding, aspects of the invention may be used inany surgical or other procedure, and may involve any suitable bodyportions, such as bone, muscle, other tissue or combinations thereof,vascular structures, digestive structures, medical implants or otherdevices, etc. Thus, aspects of the invention are in no way limited tothe specific embodiments and examples described herein.

In this illustrative embodiment, a rotator cuff tendon 2 is secured by asuture 3 relative to a humerus 1. The suture 3 is placed in the tendon2, for example, using a mattress stitch or other arrangement, and ispassed through a passageway 5 formed through the humerus 1. In thisembodiment, the passageway 5 is formed by first and second intersectingholes. A first hole 51 is formed vertically as shown in FIG. 3 from afirst opening at or near a margin between the articulating surface 11and the greater tuberosity 12 of the humerus 1. The second hole 52 isformed horizontally as shown in FIG. 3 from a lateral position on thehumerus 1. The suture 3 is secured at the second opening of the secondhole using a suture fixation device 4 that is positioned adjacent thesecond opening. Although in this embodiment the first and second holes51 and 52 are arranged at approximately right angles, the first andsecond holes may be arranged at any suitable angle and may be colinear(i.e., at a 180 degree angle relative to each other).

A wire, other material or the suture 3 may be manipulated in thepassageway 5 so as to cut through or crush the relatively softcancellous bone of the humerus in the passageway 5 so that the suturefollows a relatively straight path between the first and second openingsinto the first and second holes 51 and 52. The relatively straightpathway may be formed by a “flossing” operation, such as by using a wirethat is passed through the passageway 5 and is manipulated, e.g.,tensioned and reciprocally drawn between the first and second openings,so as to cut through or crush the cancellous bone, thereby forming arelatively straight path for the suture 3.

When deciding where to locate the first hole 51 for the passageway 5, asurgeon often will wish to first determine the final position for thetissue relative to the bone. To do so, the surgeon may wish to place asuture in the tendon 2 and tension the suture 3 (and thus the tendon 2)so that a desired position for the first hole 51 may be determined,e.g., based on the position of the tendon 2 relative to the bone whenunder tension.

In various aspects of the invention, a suture may be placed in thetendon or other tissue 2 using any suitable technique, such as astandard suturing needle and forceps, specialized suturing devices, andso on. However, in one aspect of the invention, use of a needle having ahook-shaped or curved end portion may be preferred. FIGS. 4-6 show anembodiment of a needle 6 having a hook-shaped tissue penetrating portion61 at a distal end in accordance with the invention. In the illustratedembodiment, the tissue penetrating portion 61 of the needle 6 has asemi-circular shape and is arranged at an angle, such as 90 degrees to alongitudinal axis of a straight portion 62 of the needle 6. The needle 6may be formed as a hollow tube so that the suture 3 may pass through theneedle 6. Suture may be loaded in the hollow portion of the needle 6before the surgical procedure is begun, e.g., at the time of manufactureof the needle, or at any suitable time, such as during the surgicalprocedure. In some cases, the suture may be fed into the hollow portionof the needle 6 before the tissue penetrating portion 61 is formed,e.g., by bending a tube to form a curved end shape.

The arrangement of the needle 6 may allow placement of a mattress stitchin the tissue 2 by rotating the needle as shown in FIGS. 4-6 so that atip of the tissue penetrating portion 61 passes through a top side ofthe tissue 2 and exits from a bottom side of the tissue 2 as shown inFIG. 5, and then passes upwardly through the tissue 2 to reemerge at atop side of the tissue 2 as shown in FIG. 6. At this point, the suture 3extending from the tip of the tissue penetrating portion 61 may begrasped, such as by forceps or other gripping device, and the needle 6may be rotated in reverse so as to again position the needle 6 as shownin FIG. 4, thereby leaving the suture 3 positioned in the tissue 2 toform a mattress stitch. During the passage of the suture, the tissue orother material may be held in place, or may be manipulated, by a grasperor other device inserted into the lumen of the cannula. The tissue orother material may also be held in place, or manipulated, by anotherdevice, such as a grasper or clamp positioned external to the cannula.

The tissue penetrating portion 61 of the needle 6 may have any suitableshape and may be arranged in a plane that is transverse at any angle toan axis of rotation of the tissue penetrating portion 61 when placing asuture in tissue. That is, although in the illustrated embodiment thetissue penetrating portion 61 has a semi-circular form that lies in aplane at 90 degrees to the rotation axis of the tissue penetratingportion 61 when placing a suture, the tissue penetrating portion 61 neednot have a semi-circular form and may lie at any desired angle to therotation axis. For example, the tissue penetrating portion 61 may bearranged so as to place an inclined mattress stitch in a tissue 2.Further, the needle 6 need not be used only to form a mattress stitch,but rather may be used to form any other suitable stitch type. Also, itis not necessary that the tissue penetrating portion 61 of the needle 6lie in a single plane. Instead, the tissue penetrating portion 61 maynot lie in a single plane, e.g., may have a corkscrew-type or partiallyhelical configuration.

In one aspect of the invention, all or portions of a tissue repairprocedure may be performed arthroscopically. In this case, and as isknown in the art, one or more cannulas may be provided in one or moreportals formed in the patient so as to provide access to the operativesite. In one aspect of the invention, a needle used to place a suture ina tissue, such as the needle 6 shown in FIG. 4, may be used in anarthroscopic procedure. For example, the needle 6 may be secured to acannula so that the needle may be operated by manipulation of thecannula.

FIG. 7 shows an illustrative embodiment of a needle 6 that is secured toa cannula 7. The cannula 7 may have any suitable features found incannulas used for closed or minimally-invasive surgical techniques, suchas one or more valves to resist fluid flow through the cannula 7, anopening through which to introduce a fluid pressure or vacuum, spiralthreads or other features on the cannula to aid in placement of thecannula in a portal and/or to help prevent inadvertent removal of thecannula from the portal, and so on. The cannula 7 may be arranged forany type of procedure, such as arthroscopic procedures.

The needle 6 may be secured to the cannula 7 in any suitable way. Forexample, the needle 6 may be molded into the body of the cannula 7, maybe inserted into a wall of the cannula, may be secured by adhesive,welding, clamps, fasteners, interlocking channels, open channels, or anyother suitable device. A proximal end of the needle 6 may terminate atany suitable point, such as midway between a proximal end 71 and adistal end 72 of the cannula 7 as shown, or, more preferably at aposition proximal to the proximal end 71. By having the proximal end ofthe needle 6 positioned proximally of the cannula 7, a user may bebetter able to access the suture 3 entering the proximal end of theneedle 6. The needle 6 may also be axially movable relative to thecannula, e.g., so that the tissue penetrating portion 61 may be movedaxially so as to extend away from or toward the distal end 72 of thecannula 7. In addition, although the needle 6 is shown as positioned onan outer surface of the cannula 7, the needle 6, or at least a portionthereof, may be molded into the cannula 7, positioned within the cannulalumen, positioned within the cannula wall, may be arranged within agroove on the outer surface of the cannula, and so on. Although theneedle 6 is shown as arranged in an approximately straight fashion alongthe length of the cannula 7, the needle 6 may be bent, curved orarranged in any suitable way, such as following a spiral path around anouter surface of the cannula 7.

In one illustrative embodiment, a semicircular-shaped tissue penetratingportion 61 of the needle 6 may be arranged relative to the cannula 7 sothat a centerpoint of the semicircle lies on a central longitudinal axis73 of the cannula lumen. Thus, when the cannula 7 is rotated about thecentral longitudinal axis 73, the tissue penetrating portion 61 maytravel in a circular path about the axis 73. However, it should beunderstood that the tissue penetrating portion 61 may be arranged in anysuitable way relative to the axis 73. Further, a plane in which thetissue penetrating portion 61 lies (if present) may be arranged at anyangle transverse to the axis 73, and thus need not be arranged at anangle of 90 degrees to the axis 73, as shown in FIG. 7.

In one aspect of the invention, the needle 6 may be removeably engagedwith the cannula 7 so that the needle 6 can be selectively engaged ordisengaged with the cannula 7. For example, a cannula 7 may bepositioned in a portal in use during a surgical procedure without anattached needle 6. At some point during the procedure, the surgeon maywish to attach a needle 6 to the cannula 7 and manipulate the cannula 7so as to use the needle 6 to place a suture in a tissue. The needle 6may be secured to the cannula while the cannula remains in place in theportal (e.g., by inserting the needle 6 into the cannula lumen), or thecannula may be removed from the portal, the needle attached, and thecannula and attached needle inserted into the portal.

FIG. 8 shows one illustrative embodiment in which a needle 6 may beremovably secured to a cannula 7. In this embodiment, the cannula 7includes a dovetail-shaped groove 74 into which a correspondingly shapedportion of the needle 6 is inserted. The complementary lockingarrangement used by the cannula 7 and the needle 6 need not necessarilybe dovetail-shaped as shown in FIG. 8, but rather may have any suitablearrangement. For example, the cannula 7 may have an oval-shaped channelformed in the cannula wall that engages with a complementary oval-shapedportion of the needle 7. Thus, the needle 6 may be selectively securedto the cannula 7 so that rotation or other manipulation of the cannula 7can cause the needle to be manipulated so as to place a suture in atissue. The complementary locking arrangement between the needle 6 andthe cannula 7 may also allow for axial movement of the needle 6 relativeto the cannula 7, e.g., so the tissue penetrating portion 61 can bemoved relative to the distal end 72 of the cannula 7.

FIG. 9 shows an alternative embodiment in which a needle 6 is fixed to asleeve member 63 that has one or more complementary locking featuresthat mesh with or otherwise engage with complementary features on thecannula 7. In this embodiment, the complementary locking features have atooth-like or gear-like form, but the complementary locking features maybe arranged in any suitable way. Accordingly, in this embodiment, theneedle 6 may be secured to the cannula 7 by sliding the sleeve 63 overthe distal end 72 of the cannula 7. It will be understood that ratherthan having a sleeve 63 that fits over the cannula 7, the sleeve 63 mayfit within the internal lumen of the cannula 7, or within a slot in thecannula 7, if desired.

Once a suture is placed in the tissue, such as a rotator cuff tendon,the tissue may be tensioned to determine a location for the opening ofthe first hole 51 to be formed in the bone. When performing a rotatorcuff repair, typically, a first hole 51 of the passageway 5 will beformed vertically from a superolateral position so that the first hole51 is generally aligned along the length of the humerus 1 and extendsinto the bone from an opening formed at the margin between thearticulating surface 11 and the greater tuberosity 12. This first hole51 may be formed using a perforator, such as a drill, awl, punch orother suitable device. As with other procedures performed, the firsthole 51 may be formed using an arthroscopic portal at a superolateralposition, or may be formed in an open surgical procedure.

In accordance with an aspect of the invention, a guide apparatus may beused to form the first and/or second holes of the passageway (e.g., usedto locate a starting point or opening for the first and second holes,used to orient a bone perforator when making the holes, or used alone toform the first and/or second holes), or may be used to help feed asuture or suture-like material through the passageway. For example, afirst guide member 81 may be secured relative to the first hole 51, asshown in FIG. 10. The first guide member 81 may be part of a guideapparatus 8 used to guide the formation of holes used to form apassageway in bone and/or to pass a suture or other material through thepassageway. In the illustrated embodiment, the first hole 51 has beenformed in a vertical direction along the length of the humerus 1, e.g.,by drilling the hole in a freehand manner. (Alternately, the first hole51 may be formed by forcing the first guide member 81 into the bone aswith an awl or similar instrument.) The first guide member 81 mayinclude a feature to help secure the first guide member 81 relative tothe first hole 51, such as a threaded distal end that allows the firstguide member 81 to be screwed into the bone to a desired depth in thefirst hole 51. It should be understood, however, that the distal end ofthe first guide member 81 need not be threaded, but instead mayunthreaded and inserted into the first hole 51. Alternately, the distalend of the first guide member 81 may be positioned outside of, butadjacent to, the first hole 51 so that a lumen in the first guide member81 aligns with the first hole 51. The first hole 51 may be formed so asto be deeper than thought to be needed, e.g., 0.5 cm deeper than a holedepth believed to be required. This overdrilling of the first hole 51may allow for more flexibility in positioning the first guide member 81to a desired depth in the bone.

The first guide member 81 may be arranged with respect to a referencestructure 83 used to position first and second guide members 81 and 82relative to each other with respect to the passageway 5, as is discussedin more detail below. In this illustrative embodiment, the referencestructure 83 is arranged so that the first and second guide members 81and 82 are positioned at a 90 degree angle relative to each other whenengaged with the reference structure 83. However, the referencestructure 83 may be arranged in any suitable way so as to orient thefirst and second guide members 81 and 82 at any desired angle relativeto each other, including arranging the first and second guide members 81and 82 in a co-linear fashion. Further, the reference structure 83 maybe made so as to be adjustable, thereby allowing the orientation of thefirst and second guide members 81 and 82 to be changed. For example, thearc-shaped connecting portion of the reference structure 83 may be madeso as to be adjustable in length, e.g., having one arc-shaped portionsliding relative to another arc-shaped portion to allow adjustment ofthe length of the connecting portion. Alternately, or in addition,engagement portions 84 and 85 of the reference structure 83 that engagewith the first and second guide members 81 and 82 may be adjustable inorientation relative to the arc-shaped connecting portion. In short, thereference structure 83 may be arranged in any suitable way so as toallow adjustment in the orientation of the guide members 81 and 82.

In this illustrative embodiment, the engagement portions 84 and 85include sleeves that receive at least a portion of the guide members 81and 82, e.g., the guide members 81 and 82 may be received in bores inthe sleeves. The sleeves may be arranged so that the guide members 81and 82 are movable linearly along their longitudinal axes androtationally about their longitudinal axes relative to the engagementportions 84 and 85, but otherwise may be relatively restricted in theirrange of movement. When a stop on the first guide member 81, such as aknob 811 on the proximal end of the guide member 81, contacts anengagement surface on the reference structure, such as a portion of theengagement portion 84, the second guide member 82 may be positioned bythe reference structure 83 so that its longitudinal axis passes a pointadjacent the extreme distal end of the first guide member 81. Thus, thesecond guide member 82 may be used to guide the use of a perforator 9(such as a drill, punch, awl or other bone perforating device) so thatthe perforator 9 forms a second hole 52 that intersects with the firsthole 51 at a location adjacent the distal end of the first guide member81. As discussed above, the guide member 82 may guide the movement ofthe perforator 9, e.g., guide the movement of a drill or punch insertedinto a lumen of the guide member 82 as shown, or may guide a startinglocation for forming the second hole, e.g., be used to mark or otherwisedetermine a starting location for the perforator 9, but otherwise notinteract with the perforator 9. By adjusting the depth of the firstguide member 81 in the first hole 51, the location where the second hole52 is formed can be adjusted in position (e.g., in a vertical directionas shown in the figures). For example, by screwing the first guidemember 81 into or out of the first hole 51, a surgeon may select alocation where the second hole 52 is to be formed in the bone.

In another embodiment, the engagement portion 85 may itself function asa perforator guide with the second guide member 82 being withdrawn fromthe engagement portion 85. Although in this illustrative embodiment theengagement portions 84 and 85 are shown as relatively short cylindricalsleeves, the engagement portions 84 and 85 may be arranged in anysuitable way, e.g., may be elongated so as to more closely approach thehumerus 1 and provide improved guidance for a perforator 9 and/or thefirst and second guide members 81 and 82. Further, the first guidemember 81 may be arranged so that is rotationally movable about itslongitudinal axis relative to the reference structure 83, but isotherwise held by the engagement portion 84 so that the first guidemember 81 is not movable axially. This may aid is appropriatelypositioning the first guide member 81 and reference structure 83 whenforming the second hole 52.

Upon formation of the second hole 52, the second guide member 82 may bescrewed into the second hole 52 until a stop on the second guide member82, such as a knob 821 at a proximal end of the guide member 82,contacts an engagement surface on the engagement portion 85, such as aportion of the sleeve. In this configuration shown in FIG. 11 (stops onthe first and second guide members 81 and 82 engaged with respectiveengagement surfaces on the reference structure 83), the extreme distalends of the first and second guide members 81 and 82 may be adjacent toeach other in the passageway 5 formed by the first and second holes 51and 52. Accordingly, a surgeon may be assured that if the first andsecond guide members 81 and 82 are positioned within the bone and stopson the guide members 81 and 82 are respectively in contact withappropriate engagement surfaces on the guide apparatus 8, the extremedistal ends of the guide members 81 and 82 will be positioned adjacenteach other. Thus, the surgeon may be assured that a wire 10 or otherelement may be fed into one of the guide members and retrieved from theother of the guide members, e.g., using a retriever 21 having a hook ata distal end. Such an arrangement may be advantageous when using theguide apparatus 8 in an arthroscopic procedure where the operative sitemay not be easily visualized.

Although in the above embodiment, stops on the first and second guidemembers 81 and 82 contact corresponding engagement surfaces on theengagement portions 84 and 85, the guide members 81 and 82 may bepositioned relative to the reference structure 83 in any suitable way.For example, the guide members 81 and 82 may have indicator marks onthem that may be aligned with a portion of the engagement portions 84and 85, respectively. The alignment of certain indicator marks on theguide members 81 and 82 may be used to indicate, for example, that thedistal ends of the guide members 81 and 82 are adjacent each other.Those of skill in the art will understand that the position of the guidemembers 81 and 82 relative to the reference structure 83 and relative toeach other may be determined in other ways. For example, the first andsecond guide members 81 and 82 need not necessarily be positioned sothat their distal ends are adjacent in the passageway to assist infeeding a suture from one guide member to the other. Instead, the firstand second guide members 81 and 82 may be made to suitably communicatewith the passageway in any way so as to facilitate feeding of thesuture.

In this illustrative embodiment, the first guide member 81 is shown ashaving a smaller diameter (at least at the distal end) than the secondguide member 82. This may allow the guide apparatus 8 to be used with anarrangement where the first hole 51 is smaller than the second hole 52.A relatively small first hole 51 may allow for more rapid healing and/orprovide additional space for other holes in the margin, if needed.However, it should be understood that the guide apparatus 8 and/or theholes that form the passageway 5 may be made in any suitable way, e.g.,the first and second holes 51 and 52 may have the same diameter or thefirst hole 51 may have a larger diameter than the second hole 52.

The guide apparatus 8 may also include additional guide members ifdesired, e.g., to provide for the formation of a third hole that isformed in the margin and is approximately parallel to the first hole 51,but also intersects with the second hole 52. Similarly, the guideapparatus 8 may include two pairs of guide members like that in theillustrative embodiment that are arranged to form side-by-sidepassageways 5 in the bone or other body portion.

Although in this illustrative embodiment, the guide apparatus 8 is usedto guide the formation of the second hole 52, the guide apparatus 8 neednot necessarily be used to guide the formation of the second hole 52.That is, the guide apparatus 8 may be used only to help feed the wire10, suture or other material through a passageway that is pre-formed inthe bone or other body portion. In addition, the first and second guidemembers 81 and 82 may be arranged so that the members 81 and 82 can besecured in a body portion without requiring holes to be predrilled orotherwise formed. Thus, in one embodiment, the first and second guidemembers 81 and 82 may be arranged like an awl or other device capable offorming a hole in a body portion, e.g., capable of being forced intobone, forming the passageway 5 by their entry and/or providing a meansto help feed a wire, suture or other material through the passageway 5.

Once the wire 10, suture or other material has been passed through thepassageway 5, as shown in FIG. 12, the wire 10 may be used to pull thesuture 3 through the passageway 5. Prior to being used to pull thesuture 3 through the passageway 5, the wire 10 or other material may beused to create a relatively straight pathway for the suture 3 once thesuture 3 is tensioned and fixed in place. For example, the wire 10 maybe tensioned between the first and second openings 53 and 54 of thefirst and second holes 51 and 52 or otherwise manipulated so as to cutor crush the body portion, e.g., bone, between the first and secondopenings 53 and 54. Such manipulation of the wire 10 may perform a kindof “flossing” effect in the bone, allowing the suture 3 to follow a morestraight pathway through the passageway 5, reducing the length of suture3 needed between the rotator cuff 2 and a point of fixation of thesuture 3, e.g., near the second opening 54. The wire 10 may have barbsor other saw-like features to aid in cutting bone and forming thepathway. Of course, the more straight pathway could be formed bymanipulating the suture 3 itself, e.g., by tensioning the suture 3 whensecuring the tendon or other material. Reducing the length of suture 3in the passageway 5 may improve the suture's ability to maintainappropriate tension on the rotator cuff 2, e.g., by reducing the amountof stretch of the suture when under tension.

After the suture 3 has been passed through the passageway 5, the suture3 may be engaged with a suture fixation device 4 as shown in FIG. 13.Although use of a suture fixation device is not required, the suturefixation device 4 may improve an ability to securely fixate the suture 3(and the tissue 2) relative to the bone. The suture fixation device 4may be arranged in any suitable way, but in this illustrative embodimenthas an arrangement similar to a button. For example, the suture fixationdevice 4 may have two through holes formed in a disk-shaped memberthrough which leading ends of the suture 3 are passed. The suture ends 3may be passed through respective holes in the suture fixation device 4using one or more feed members 41. The feed members 41 may have anelongated shape that is passed through a respective hole in the suturefixation device 4. A loop at one end of the feed member 41 may receivean end of the suture 3 and thereafter the feed member 41 may be pulledthrough a respective hole in the suture fixation device 4 so as to pullthe suture 3 through the hole. Of course, it should be understood thatthe suture 3 may be fed through the suture fixation device 4 in anyother suitable way. When performing this technique arthroscopically, thesuture 3 may be fed through the suture fixation device 4 either insideor outside of the body cavity.

As shown in FIG. 14, after the suture 3 is engaged with the suturefixation device 4, the suture fixation device 4 may be positionedrelative to the second opening 54 of the passageway 5 using an applier42 which removably engages with the suture fixation device 4 and may beselectively disengaged from the suture fixation device when the suturefixation device 4 is positioned as desired. As shown in FIG. 15, theapplier 42 may have a pair of tines 421 that engage with recesses orother features on the suture fixation device 4 so as to removably engagewith the suture fixation device 4. The tines 421 may be resilient sothat the tines are squeezed together when engaged with the suturefixation device 4. Thus, an elastic force biasing the tine ends apartmay help maintain engagement of the tines with the grooves 48 in thesuture fixation device 4. Alternately, the tine ends may be force-fitinto grooves 48 in the suture fixation device so that engagement ismaintained based on friction. Of course, it will be understood that theapplier 42 may engage with the suture fixation device 4 in any othersuitable way, such as a screw-in or snap configurations.

With the suture fixation device 4 in place relative to the secondopening 54, the suture 3 may be tensioned so as to appropriatelyposition the rotator cuff 2 relative to the humerus 1. At this point,the suture 3 may be fixed relative to the suture fixation device 4, suchas by tying a knot with the suture ends. Thus, the suture fixationdevice 4 may provide not only a structure to support the suture knot,but also may spread the force of the suture 3 to portions of therelatively hard cortical bone surrounding or otherwise adjacent to thesecond opening 54. By having the suture fixation device 4 engage withthis cortical bone, the suture fixation device 4 may provide arelatively stable and secure fixation point for the suture 3. The suturefixation device 4 may also incorporate a mechanism for knotless fixationof the suture, such as an interference pin, a locking passageway, alocking cap, etc.

Although in the illustrative embodiment described above both ends of thesuture 3 are passed through the passageway 5 and secured at or near thesecond opening 54 of the passageway 5, the suture 3 may be secured inother ways, such as by passing one end of the suture 3 through thepassageway 5 and passing another end of the suture 3 around the outsideof the bone (e.g., over a portion of the greater tuberosity) where it issecured to the other suture end. In another embodiment, two passageways5 may be formed through the bone and one end of the suture 3 may bepassed through one passageway and the other end of the suture 3 may bepassed through the other passageway. The suture ends may then be securedto each other at or near respective second openings of the passageways 5on the lateral side of the humerus 1. In yet another embodiment, two ormore first holes 51 may be formed so as to intersect with one or moresecond holes 52. Suture 3 may be passed through the two or more firstholes 51 and be secured at the second opening 54 of the one or moresecond holes 52. Such an arrangement may allow for the use of a singlesecond hole 52 and suture fixation device 4 to secure the rotator cuffat two or more points on the humeral head using two or more sutures thatpass through different first holes 51. Other suture fixation techniquesmay be used as desired.

FIGS. 16A-B and 17A-B show illustrative embodiments of suture fixationdevices 4 in accordance with the invention. In these embodiments, thesuture fixation device 4 includes a restriction in a pathway through thesuture fixation device 4 so that suture or other material passingthrough the suture fixation device is relatively freely moved in onedirection through the pathway, but movement of the suture or othermaterial in the other direction in the pathway is resisted. For example,movement of a suture though the suture fixation devices shown in FIGS.16A and 17A in a direction to the left may be freely allowed, whilemovement of the suture toward the right may be resisted. This may aid intensioning the suture 3 because the suture 3 may be pulled from thesecond hole 52 through the suture fixation device 4 until the rotatorcuff or other tissue is appropriately positioned. Thereafter, tension onthe suture may be temporarily released, e.g., in preparation for forminga knot, but movement of the suture back through the suture fixationdevice 4 may be resisted so that the rotator cuff or other tissue ismaintained in place until the suture knot is tied or otherwise issecured.

In the FIG. 16 embodiment, the suture fixation device includes an outerend having a flange portion 43 that is sized and arranged to contact thecortical bone adjacent the opening in the passageway at which the suturefixation device 4 is positioned, e.g., the second opening 54. One ormore pathways 44 may be formed through the suture fixation device 4,such as by a hole or holes formed through the flange 43 (see also FIG.15). Instead of having multiple holes, the pathway 44 may include asingle slot arranged to receive one or more sutures. A recess 49 may beprovided in the flange portion 43 to receive one or more knots, ifformed with the suture(s) in the pathway 44. A pair of duck bill members45 at an inner end of the suture fixation device 4 may extend rearwardlyfrom the flange 43 and may be arranged as to be positionable in thesecond hole 54. The duck bill members 45 may be separated from eachother by a groove that extends across the inner end of the suturefixation device 4 and be resiliently biased toward each other so as toresist the passage of suture or other material through the pathway 44.One or both of the duck bill structures 45 may include serrations 46 orother features that may aid in engaging a suture or other material. Inthe FIG. 16 embodiment, the groove separating the duck bill structures45 extends to the flange portion 43 so that the structures 45 arepivotable at a point near the flange portion 43.

The FIG. 17 embodiment similarly includes a flange 43 and one or morepathways 44. Duck bill structures 45 are also provided. However, in thisembodiment rather than being hinged at a point near respectiveconnection points with the flange 43, the duck bill portions 45 arehinged at a point positioned away from the flange 43. Providing theeffective hinge points for the duck bill structures 45 in this mannermay provide improved engagement of the duck bill structures 45 with asuture or other material when the suture is urged to move from the outerend toward the inner end through the pathway 44. That is, if the sutureis pulled to move toward the inner end, serrations 46 or other featureswill engage with the suture and increased force on the suture will causean increased force urging the duck bill structures 45 to move towardeach other and further squeeze the suture. The duck bill structures inthe FIGS. 16 and 17 embodiments or other suitable suture engagementarrangements (such as interference pins, locking caps, etc.) may providea knotless fixation for the suture. Alternatively, the structures mayresist movement of the suture so as to aid the surgeon's ability tomaintain tension on the suture while forming a knot.

Although this embodiment depicts the flange of the device resting on theouter cortical surface of the bone, the device may be positioned in ahole which has a counterbore, or countersink, in order to prevent anyinterference between the flange and other bone or tissues that may comein contact with the site either at rest or during movement. Even in thecase where the device is positioned in a counterbore or countersinkfeature, the device may contact cortical bone. Alternately, the devicemay only contact the outer, cortical surface of the bone, and not extendinto a hole in the bone.

Of course, it should be understood that suture fixation devices may beprovided in any suitable form. For example, the duck bill portions 45extending from the flange 43 in the FIGS. 16 and 17 embodiments may besized to closely fit into a mating hole formed in bone. This close fitmay help in maintaining the suture fixation devices 4 in a desiredposition in the bone. Alternately, the duck bill structures 45 may beformed so as to be tapered on their outer surfaces. Thus, when thesuture fixation device 4 is inserted into a hole in the bone, thetapered surfaces of the duck bill structures 45 may contact the sides ofthe hole and urge the duck bill structures to move toward each other asthe suture fixation device 4 is pressed into the hole. In anotherembodiment, a portion of the suture fixation device 4 that is insertedinto a hole may be threaded or otherwise be arranged so as to engage thehole and help prevent the suture fixation device from falling from thehole, e.g., before the suture is secured in place. There are manyvariations of the mechanism form to retain the suture with respect tothe device. Some of these forms may require a knot for final fixation.Other capturing mechanisms may provide sufficient locking of the suturesuch that a knot is not required. Theses are typically known as“knotless” devices.

Having thus described several aspects of at least one embodiment of thisinvention, it is to be appreciated various alterations, modifications,and improvements will readily occur to those skilled in the art. Suchalterations, modifications, and improvements are intended to be part ofthis disclosure, and are intended to be within the spirit and scope ofthe invention. Accordingly, the foregoing description and drawings areby way of example only.

1. A method for surgical repair, comprising: forming a first hole into abone; positioning a distal end of a first guide into the first hole tolocate the first guide and an attached reference structure relative tothe bone, the first guide having a first passage that extends to thedistal end of the first guide; providing a suture retriever in the firstpassage of the first guide; positioning a second guide, which is movablymounted to the reference structure, relative to the bone so that adistal end of the second guide is adjacent the bone; forming a secondhole in the bone using a perforator that is guided in movement by apassage of the second guide while the distal end of the first guide ispositioned in the first hole, the second hole being transverse to andintersecting with the first hole and forming a passageway through thebone; providing a suture into the passage of the second guide so thatthe suture extends into the second hole while the first and secondguides remain in communication with the first and second holes; andretrieving the suture from the second hole by moving the sutureretriever in the first passage of the first guide so a distal end of thesuture retriever extends from the distal end of the first guide toengage with the suture, and moving the suture retriever in the firstpassage with the engaged suture to draw the suture to the distal end ofthe first guide while the distal end of the first guide remains in thefirst hole.
 2. The method of claim 1, wherein the step of retrievingcomprises: withdrawing the suture retriever and engaged suture from thefirst passage of the first guide.
 3. The method of claim 1, furthercomprising inserting the first and second guides into an arthroscopiccannula.
 4. The method of claim 1, wherein the step of positioning adistal end of the first guide comprises: securing a threaded end of thefirst guide in the first hole.
 5. The method of claim 1, wherein thedistal ends of the first and second guides are each located at leastpartially in the first and second holes, respectively during the step ofretrieving.
 6. The method of claim 5, wherein the first and secondguides are respectively positioned in an arthroscopic cannula and thereference structure is positioned outside of a body cavity.
 7. Themethod of claim 1, wherein the first passage of the first guide has asmaller diameter than the passage of the second guide.
 8. The method ofclaim 1, wherein the passageway is formed in a humerus, the methodfurther comprising: securing a rotator cuff tendon to the humerus usingthe suture extending in the passageway.
 9. The method of claim 8,wherein the step of securing a rotator cuff tendon comprises: securingthe suture to the humerus using a suture fixation device positioned atleast partially outside of the passageway.
 10. The method of claim 1,wherein the step of positioning the second guide comprises: moving thesecond guide relative to the reference structure and relative to thebone in a direction along a length of the passage of the second guide.11. The method of claim 1, wherein the first and second guides eachinclude a tube that defines the passages of the first and second guides,respectively.